Parent/Guardian Information *

First Name

Last Name

Parent Home Phone No.

(###)

###

####

Parent Cell Phone No. *

(###)

###

####

Preferred Contact Method *

Phone Call

Text

Email

Child's Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Child's Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Does your child have a hearing loss?

Yes, my child has hearing loss

No

Does your child have a developmental disability?

Cerebral Palsy

Downs Syndrom

Other

None

By agreeing to include your child’s information in the IHN Participant Registry, their information, brain images, test results, and information obtained by the Institute for Human Neuroscience staff will be stored electronically in a secure and password protected location. By agreeing, you may be contacted by IHN research staff for future research studies your child may qualify for. Your child’s participation in the IHN Participant Registry is completely voluntary, and you have the right to stop at any time or for any reason. There is no penalty for non-participation or withdrawal and your refusal will not affect in any way the services your child will receive now, or in the future, from IHN, BTNRH or any associated clinics.

I Agree

I Do Not Agree